Nutricia. Nutrition and Chronic Obstructive Pulmonary Disease

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1 Nutricia Nutrition and Chronic Obstructive Pulmonary Disease

2 Outline Introduction to COPD What is COPD Prevalence Impact Malnutrition in COPD Prevalence Consequences Nutritional requirements of patients with COPD Energy Protein Micronutrients Nutritional management of COPD Evidence for oral nutritional support in COPD Case study

3 1 Introduction

4 What is COPD? Chronic Obstructive Pulmonary Disease Progressive, multi-organ, systemic disease Largely irreversible Characterised by airflow obstruction Source: NICE Chronic Obstructive Pulmonary Disease (update) Clinical Guideline CG

The Prevalence of COPD in the UK An estimated 3 million people have chronic obstructive pulmonary disease (COPD) Only 900,000 are currently diagnosed It is the fifth most common

5 The Prevalence of COPD in the UK An estimated 3 million people have chronic obstructive pulmonary disease (COPD) Only 900,000 are currently diagnosed It is the fifth most common cause of death in England and Wales Accounting for approximately 30,000 deaths each year Source: NICE Chronic Obstructive Pulmonary Disease (update) Clinical Guideline CG

Impact of COPD on the NHS COPD is one of the most costly inpatient conditions treated by the NHS Accounting for more than one million 'bed days each year The second largest cause of

6 Impact of COPD on the NHS COPD is one of the most costly inpatient conditions treated by the NHS Accounting for more than one million 'bed days each year The second largest cause of emergency admission in the UK One in eight (130,000) emergency admissions to hospital are the result of COPD Source: NICE Chronic Obstructive Pulmonary Disease. Quality Standards, QS

7 Impact of COPD on the NHS High direct costs to the UK healthcare system Estimation of between million per year 1 High prescribing costs in primary care Estimation of million 2 Improvement in the management and effectiveness of treatments is likely to result in: 5% fewer admissions to hospital million savings each year 2 1. NICE Chronic Obstructive Pulmonary Disease (update) Clinical Guideline CG NICE National costing report: chronic obstructive pulmonary disease CG

8 2 Malnutrition in COPD

9 Mortality (%) Prevalence of Malnutrition in COPD Up to 60% of COPD inpatients and 45% of COPD outpatients are malnourished 1 Increased risk of malnutrition due to nutritional requirements and nutritional intake p<0.001 Low BMI (<20 kg/m 2 ) is a predictor of mortality in this patient group BMI classification (kg/m 2 ) 1. Stratton RJ, et al. Oxford: Cabi publishing; Ezzell L, et al. Am J Clin Nut. 2000;72: Collins PF, et al. Clinical Nutrition 2010;5,S2:17.

Malnutrition can have serious consequences Peripheral muscle strength Quality of Life Respiratory Muscle Function Morbidity Malnutrition in COPD can have serious

Clinical Nutrition 2010;5,S2:17 3. Gupta B, Kant S, Mishra R, Verma S. J Clin Med Res, 2010 Mar 20; 2(2): 68-74. 4. Ferreira IM, Brooks D, White J, Goldstein R.

10 Malnutrition can have serious consequences Peripheral muscle strength Quality of Life Respiratory Muscle Function Morbidity Malnutrition in COPD can have serious consequences 1-6 Healthcare costs Activity Mortality Fatigue 1. Ezzell L and Jensen GL. Am J Clin Nut 2000;72: Collins PF et al. Clinical Nutrition 2010;5,S2:17 3. Gupta B, Kant S, Mishra R, Verma S. J Clin Med Res, 2010 Mar 20; 2(2): Ferreira IM, Brooks D, White J, Goldstein R. Cochrane Database Syst Rev Vermeeren MA et al. Respir Med, 2006; 100: , 6. Collins PF, Stratton RJ, Elia M. Proceedings of the Nutrition Society, 2011; 70 (OCE5): E324.

11 Consequences of Malnutrition in COPD Reduced lung function and respiratory muscle wasting can result in: Increased energy expenditure by up to 20% 1 Decreased strength, endurance and exercise capacity 1 Reduced sensitivity to hypoxic stimuli 2 Respiratory failure 1 Delayed weaning from mechanical ventilation 1 1. Ezzell L, et al. Am J Clin Nut, 2000;72:1415-6, 2. Gupta B, et al. J Clin Med Res. 2010;2:68-74.

12 Consequences of Malnutrition in COPD Skeletal muscle wasting results in 1 : Increase risk of mortality independent of BMI Depletion may also occur with a normal or high BMI Reduced muscle strength Decreased exercise capacity and exercise response 1. Ferreira IM, et al. Cochrane Database Syst Rev

13 3 Nutritional Requirements in COPD

14 Increased Energy Requirements Increased energy metabolism Increased REE by up to 20% 1 Systemic inflammation 2 Altered substrate metabolism Increased lipolytic response 2 Reduced dietary intake Dyspnoeic symptoms with chewing and swallowing 3 Impact of gastric filling on lung capacity 2 Impact of systemic inflammation on appetite regulation 2 1. Ezzell L, et al. Am J Clin Nutr. 2000;72: Kim HC, et al. Int J Chron Obstruct Pulm Dis. 2008;3: Gandy J, Eds. Manual of Dietetic Practice. 5th edn. Wiley Blackwell Publishing, 2014.

15 Increased Protein Requirements Patients with COPD may have increased protein requirements 1,2 Protein intakes in both hospital and care home patients is often sub-optimal 1 New ESPEN recommendations for protein intake 2 : g/kg/day for all healthy older people g/kg/day for older people with acute or chronic illness Protein intakes of 1.5g/kg/day may be optimal during IECOPD 3 During illness patients can develop a protein gap Gandy J, Eds. Manual of Dietetic Practice. 5th edn. Wiley Blackwell Publishing, Deutz N, et al. Clin Nutr. 2014;33: Milne AC, et al. Cochrane Database Syst Rev 2009; 2:CD003288, 4. Vermeeren MA, et al. Eur Respir J. 1997;10: WHO. Keep fit for life: Meeting the nutritional needs of older persons, NICE. Nutrition support in adults (Clinical Guidelines 32) Todorovic V, et al. A pocket guide to clinical nutrition. 4th ed. BDA, Finch S, et al. National Diet and Nutrition Survey: People Aged 65 Years and Over, Vol 1. The Stationary Office, 1998.

16 Increased Micronutrient Requirements Micronutrient intake is likely to be compromised in individuals who have a diet deficient in energy and protein 1 Micronutrients are important for: Regulation of numerous body processes Optimal use of macronutrients (protein, fat and carbohydrate) Any form of nutritional support should consider the provision of adequate micronutrients Mar 15, Gandy J. Manual of Dietetic Practice. 5th edn. Wiley Blackwell Publishing, 2014.

17 4 Nutritional Management in COPD

18 NICE Guidelines (CG101) BMI should be calculated in patients with COPD Normal range is 20-25kg/m 2 If the BMI is abnormal, or changing over time: Refer for dietetic advice If the BMI is low: Give oral nutritional supplement (ONS) to increase total calorific intake Encourage patient to take exercise to augment the effects of ONS Source: NICE Chronic Obstructive Pulmonary Disease (update) Clinical Guideline CG

19 Department of Health Ensure patients receive appropriate treatment through: Evidence based treatment Pro-active management Regular reviews 1 The emphasis is on preventing hospital admissions and managing patients in the community where possible 2 1. Department of Health [ ] 2. Department of Health. [ ]

20 Management of Malnutrition Nutrition support strategies NICE (2006) recommends the use of various nutrition support strategies to improve dietary intake 1 Dietary counselling Food fortification Oral nutritional supplements (ONS) Nutritional goals should be agreed for patients at risk of malnutrition Weight gain: Until recently, weight loss was considered an inevitable part of the disease process Weight gains of 2kg have been associated with functional improvements 2 and can be used as a therapeutic target 1. NICE. Nutrition support in adults (Clinical Guidelines 32) Collins PF, et al. Respirology. 2013;18:

21 5 Evidence for Oral Nutrition Support (ONS) in COPD

22 ONS improve outcomes Improves quality of life Significantly improves patients nutritional intake ONS in COPD 1-3 Significantly improves hand grip strength Significantly improves exercise performance Significantly improves respiratory muscle strength 1. Collins PF, Stratton RJ, Elia M. AM J Clin Nutr, 2012 Jun; 95(6): Collins PF, Elia M, Stratton RJ. Respirology, 2013 May 18(4): Ferreira IM, Brooks D, White J, Goldstein R. Cochrane Database Syst Rev

23 Key papers that support the use of ONS in COPD Nutritional support in chronic obstructive pulmonary disease: a systematic review and meta-analysis (Collins, Stratton & Elia, 2012) Nutritional support and functional capacity in chronic obstructive pulmonary disease: A systematic review and meta-analysis (Collins, Stratton & Elia, 2013) Nutritional supplementation for stable chronic obstructive pulmonary disease (Review) (Ferreira IM, Brooks D, White J, Goldstein R. Cochrane review 2012)

24 Collins et al (2012) Systematic review and meta-analysis to clarify the efficacy of nutritional support in improving intake, anthropometric measures, and grip strength in stable COPD 13 RCTs of nutritional support (ONS 11; dietary advice - 1; enteral tube feeding 1) Nutritional support, mainly ONS: Significantly improves total nutritional intake including energy and protein Leads to significant weight gain and increased hand grip strength Source: Collins PF, et al. AM J Clin Nutr. 2012;95:

25 Collins et al (2013) Systematic review and meta-analysis to clarify the effectiveness of nutritional support in improving functional outcomes in patients with COPD 12 RCTs of nutritional support (ONS 10; dietary advice - 1; enteral tube feeding 1) Nutritional support significantly improves: Inspiratory and expiratory muscle strength Hand grip strength Highly significant improvements are associated with weight gains of 2kg The review also found nutritional support resulted in: Improved exercise performance and enhancement of exercise programmes Improvements in quality of life Source: Collins PF, et al. Respirology, 2013;18(4):

26 Ferreira et al (2012) Cochrane review to assess the impact of nutritional support on anthropometric measures, pulmonary function, respiratory and peripheral muscle strength, endurance, functional exercise capacity and healthrelated quality of life (HRQoL) in COPD. Nutritional supplementation promotes: Significant weight gain among patients with COPD (especially in those who are malnourished) Significant improvement from baseline in: Body composition Fat free mass index/fat free mass and fat mass/fat mass index Mid Arm Muscle Circumference (MAMC, a measure of muscle mass) Improvement in skinfold thickness (measure of fat mass) Exercise capacity 6 min walk test Health related quality of life Source: Ferreira IM, et al. Cochrane Database Syst Rev

27 Evidence for High Protein ONS Systematic review and meta analysis of the effects of high protein* ONS in elderly (including those with COPD) 30% reduction in hospital readmissions and reduced length of hospital stay 1 19% reduction in complications such as pressure ulcers/wounds, non-healing fractures and infections 1 Improvement in handgrip strength 1, a predictor of health-related quality of life in patients with COPD 2 *At least 20% of total energy from protein 3 1 Cawood AL, et al. Ageing Res. Rev 2012;11: Ansari K, et al. Pak J Med Sci. 2007;23: Regulations (EC) No. 1924/2006, 2006.

28 6 COPD Case Study

29 Case Study Mrs. Jones 84 year old female Presenting condition: infective exacerbation of COPD Referred for oral nutrition support MHx: Hypercholesterolaemia, COPD Medications: seretide, ventolin, atorvastatin SHx: lives at home alone, supportive family

30 Case Study Anthropometry Weight: 43kg / 6st 11lb Height: 159cm / 5ft 2.5in BMI: 17.0kg/m2 (underweight, reference range: 20-25kg/m2) Wt Hx: 2/12 ago 45.5kg (5.5% weight loss 2/12) Moderate signs of muscle wasting and subcutaneous fat loss Biochemistry Nil current issues, checked and replete

Case Study Clinical Anorexia daily last 2/52 Increasing SOB 1/12 Receiving IV ABx O2 via nasal prongs Nil nausea, vomiting or diarrhoea Nil oedema or ascites MUST = 4 Estimated Requirements Energy:

31 Case Study Clinical Anorexia daily last 2/52 Increasing SOB 1/12 Receiving IV ABx O2 via nasal prongs Nil nausea, vomiting or diarrhoea Nil oedema or ascites MUST = 4 Estimated Requirements Energy: 1450kcal 1 Protein: 60g 2 Fluid: 1300ml 3 1. Henry CJ. Public Health Nutr. 2005;8: (Activity factor: 20%, Stress factor: 20%) 2. Deutz NEP, et al. Clin Nutr. 2014;33: ( g/kg/day ) 3. Todorovic VE, et al. A pocket guide to clinical nutrition. 4 th ed. British Dietetic Association, 2011.(30-35ml/kg/day)

32 Case Study: Diet History Meal Food Consumed Energy (kcal) Protein (g) Breakfast Lunch Dinner ¼ bowl porridge with milk 1 slice bread with butter + jam ½ cup orange juice Tea with milk and 1 sugar ¼ tuna and mayonnaise sandwich ½ pot fruit yoghurt ½ cup orange juice Small bowl of tomato soup 1 slice of bread with butter ½ serve custard Snacks 2 biscuits Tea with milk and 1 sugar Total

33 Case Study Nutritional diagnosis Inadequate energy and protein intake Related to: Anorexia Drowsiness Increased requirements with infective exacerbation of COPD As evidenced by: BMI: 17kg/m 2 5.5% weight loss 2/12 current intake = ~65% estimated energy requirement (600kcal deficit) and ~40% estimated protein requirement (36g deficit)

34 Case Study Nutritional intervention: 1. Educate patient on the importance of good nutrition for overcoming infection and preventing further weight loss 2. Change to HEHP diet with fortified snacks and determine diet preferences to tailor food service provision 3. Initiate an ONS, such as Fortisip Compact Protein BD (600kcal, 36g protein) 4. Discuss with nursing staff the importance of encouraging oral intake and assisting with feeding 5. Commence food chart 6. Weekly body weights 7. Review

35 Compliance is vital Patients with COPD may struggle to drink large volumes due to: Reduced appetite 1 Early satiety 2 Shortness of breath 3,4 Low motivation and depression 2,5 Compliance 6 and nutrient intake 2 is improved with small volume, higher energy density ONS 1. Sturm K, et al. Am J Clin Nutr. 2004;80: Nieuwenhuizen WF, et al. Clin Nutr. 2010;29: Devereux G. BMJ. 2006;332: Walke LM, et al. Arch Inter Med, 2007;167: Katona C. Europ Neuropsychopharm. 2000;10:S Hubbard GP, et al. Clin Nutr Suppl. 2012;31:

36 Considerations when choosing an ONS Volume High protein Style Energy density Micronutrients Flavours

37 Benefits of ONS ONS have an important role to play in the management of undernutrition but are only effective when used appropriately Ways to achieve appropriate use of ONS: Any ONS must be used in conjunction with encouraging oral intake and food fortification ONS are not intended to be meal replacements ONS are best used between meals along with other snacks if the individual can manage these ONS must only be given to the individual for whom they are prescribed and used under medical supervision

38 Summary Management of COPD should focus on the improvement or maintenance of body function and QOL Patients with COPD may have increased nutritional requirements, including protein 1-5 Malnutrition is prevalent among patients with COPD and can have serious consequences for both the individual and local health economy 6 Evidence suggests that the use of ONS is cost-effective and can result in clinical and functional benefits for patients with COPD Ezzell L, et al. Am J Clin Nutr. 2000;72: Kim HC, et al. Int J Chron Obstruct Pulm Dis. 2008;3: Gandy J, Eds. Manual of Dietetic Practice. 5th edn. Wiley Blackwell Publishing, Deutz N, et al. Clin Nutr. 2014;33: Milne AC, et al. Cochrane Database Syst Rev 2009; 2:CD003288, 6. Stratton RJ, et al. Oxford: Cabi publishing; Collins PF, et al. AM J Clin Nutr. 2012;95: Collins PF, et al. Respirology, 2013;18(4): Ferreira IM, et al. Cochrane Database Syst Rev

39 References Ansari K, Shamssain M, Keaney NP, et al. Predictors of quality of life in chronic obstructive pulmonary disease patients with different frequency of exacerbations. Pak J Med Sci. 2007;23: Cawood AL, Elia M, Stratton RJ. Systematic review and meta-analysis of the effects of high protein oral nutritional supplements. Ageing Res Rev. 2012;11: Collins PF, Stratton RJ, Kurukulaaractchyx R, et al. MUST predicts 1-year survival in outpatients with chronic obstructive pulmonary disease. Clin Nutr. 2010;5:17. Collins PF, Elia M, Stratton RJ. Nutritional support and functional capacity in chronic obstructive pulmonary disease: a systematic review and meta-analysis. Respirology, 2013;18: Collins PF, Stratton RJ, Elia M. An economic analysis of the costs associated with weight status in chronic obstructive pulmonary disease (COPD). Proc Nutr Soc. 2011;70:E324. Collins PF, Stratton RJ, Elia M. Nutritional support in chronic obstructive pulmonary disease: a systematic review and meta-analysis. AM J Clin Nutr. 2012;95: Department of Health. An outcome strategy for Chronic Obstructive Pulmonary Disease (COPD) and asthma in England [internet]. London: Department of Health; Retrieved from: [cited Mar 15, 2016] Department of Health. Consultation for strategy of services for COPD in England. London: Department of Health; Retrieved from: Deutz N, Bauer JM, Barazzoni R, et al. Protein intake and exercise for optimal muscle function with aging: Recommendations from the ESPEN Expert Group. Clin Nutr. 2014;33: Devereux G. ABC of chronic obstructive pulmonary disease. BMJ. 2006;332: Ezzell L, Jensen GL. Malnutrition in Chronic Obstructive Pulmonary Disease. Am J Clin Nutr. 2000;72:

40 References Ferreira IM, Brooks D, White J, et al. Nutritional supplementation for stable chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2012;12:CD Finch S, Doyle W, Lowe C, et al. National Diet and Nutrition Survey: People Aged 65 Years and Over, Vol 1. London: The Stationary Office, Food Standards Agency. McCance and Widdowson s The Composition of Foods. 6th ed. Cambridge: Royal Society of Chemistry, Gandy J, Ed. Manual of Dietetic Practice. 5 th ed. Oxford: Wiley Blackwell Publishing, Gupta B, Kant S, Mishra R, et al. Nutritional status of chronic obstructive pulmonary disease patients admitted in hospital with acute exacerbation. J Clin Med Res. 2010;2: Hubbard GP, Elia M, Holdoway A, et al. A systematic review of compliance to oral nutritional supplements. Clin Nutr. 2012;31: Katona C. Managing depression and anxiety in the elderly patient. Europ Neuropsychopharm. 2000;10:S Kim HC, Mofarrahi M, Hussain S. Skeletal muscle dysfunction in patients with chronic obstructive pulmonary disease. Int J Chron Obstruct Pulmon Dis. 2008;3: Milne AC, Potter J, Vivantia A, et al. Protein and energy supplementation in elderly people at risk from malnutrition. Cochrane Database Syst Rev. 2009;2:CD Nation Institute for Health and Clinical Excellence (2010) Chronic Obstructive Pulmonary Disease (update). NICE guideline (CG101). National Institute for Health and Clinical Excellent (2011).Chronic Obstructive Pulmonary Disease. NICE quality standard 10.

41 References National Institute for Health and Clinical Excellent (2011). National costing report: chronic obstructive pulmonary disease. NICE guideline (CG101). National Institute for Health and Clinical Excellent (2011). Nutrition support in adults. NICE guideline (CG 32). Nieuwenhuizen WF, Weenen H, Rigby P, et al. Clin Nutr. 2010;29: Regulations (EC) No. 1924/2006, European Parliament and of the Council of 20 December 2006 on nutrition and health claims made on foods. Official Journal of the European Union, L404. Stratton RJ, Green CJ, Elia Ml. Disease-related malnutrition: an evidence based approach to treatment. Oxford: Cabi publishing, Sturm K, Parker B, Wishart J, et al. Energy intake and appetite are related to antral area in healthy young and older subjects. Am J Clin Nutr. 2004;80: Todorovic V, Micklewright A, Eds. A pocket guide to clinical nutrition. 4th ed. BDA, Vermeeren MA, Schols AM, Wouters EF. Effects of an acute exacerbation on nutritional and metabolic profile of patients with COPD. Eur Respir J. 1997;10: Vermeeren MA, Creutzberg EC, Schols AM, et al. Prevalence of nutritional depletion in a large outpatient population of patients with COPD. Respir Med. 2006;100: Walke LM, Byers AL, Tinetti ME, et al. Range and severity of symptoms over time among older adults with chronic obstructive pulmonary disease and heart failure. Arch Inter Med 2007;167: WHO. Keep fit for life: Meeting the nutritional needs of older persons, Wolfe RR, Miller SL, Miller KB. Optimal protein intake in the elderly. Clin Nutr. 2008;27:

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Nutricia. The importance of protein: an update on the latest evidence

Nutricia. The importance of protein: an update on the latest evidence Nutricia The importance of protein: an update on the latest evidence Outline Introduction Review the definition, function and dietary sources of protein Protein Requirements High Protein ONS Evidence Case